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Bionied, 
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•' 


K6l5t 

1866 


THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


TREATMENT 


OP 

It 


CONGENITAL    CLEFT    PALATE. 


By  NO  Par  AN  W.  KhYGSLEY. 


READ  BEFORE  THE  SOCIETY  OF   DENTAL   SURGEONS  OF  THE 
CITY  OF  NEW  YORK,  AT  THE   COOPER  INSTITUTE, 

•  SEPTEMBER   27tji.   1865 


Published  !>y  Order  ot'tho  Society. 


N  E  W    Vol!  K  : 

PRINTED     BY     THE    NEW     YOKE     PRINTING     COMPANY, 
•in  Ann  Stkbbt,  ins  81,  88,  k  88  Centre  Bt» 

1866.  '  ' 


TREATMENT  OF  CONGENITAL  CLEFT  PALATE. 


Mr.  President  and  Gentlemen  : — Allow  me  to  thank  you 
for  the  honor  you  have  done  me  in  inviting  me  to  address 
you  on  this  occasion,  and  also  to  thank  the  joint  committee  of  the 
New  York  and  Brooklyn  societies,  for  their  efforts  to  make  the 
evenings  devoted  to  the  discussion  of  the  treatment  of  Cleft 
Palate  interesting  to  both  dentists  and  surgeons. 

To  comply  as  far  as  possible  with  the  arrangements  of  that 
committee,  in  devoting  two  evenings  to  this  subject,  I  propose 
at  this  first  meeting  and  in  this  paper  to  direct  your  attention  to 
the  evils  of  this  deformity,  and  a  discussion  of  the  relative  merits 
of  surgical  operations  and  mechanical  appliances  for  their 
i-emedy ;  and  the  subsequent  meeting  to  a  description  of  the 
means  used  in  the  construction  and  adaptation  of  artificial 
palates. 

An  experience  of  over  six  years,  and  the  successful  application 
of  artificial  vela  for  nearly  thirty  different  patients,  coming  from 
various  parts  of  the  world,  has  enabled  me  to  form  quite  decided 
opinions  on  this  subject;  and  it  is  my  desire  at  these  meetings  to 
impart  all  the  information  I  possess,  and  has  been  my  endeavor 
L,o  adapt  this  paper  to  the  most  ordinary  comprehension. 

The  attention  of  both  surgeons  and  dentists  has  been  directed 
nuch  more  to  this  deformity  within  the  last  few  years  than  for- 
merly ;  and  as  the  cases  presented  grew  more  manageable  with 
increasing  skill,  the  interest  in  them  and  the  number  of  cases 
seemingly  also  increased.  Whether  there  be  an  increase  propor- 
tionately, or  whether  the  apparent  increase  is  the  result  of 
greater  attention  given  to  the  subject,  the  writer  has  no  statistics 
or  other  means  of -knowing.  It  must,  in  the  nature  of  things,  be 
coeval  with  other  ills  to  which  the  human  subject  is  heir.  Fre- 
quent reference  is  made  by  the  older  authors  to  its  exist- 
ence, but  the  primal  cause  of  this  deformity  thus  far  remains 
unknown  and  beyond  our  control ;  no  research  has  unfolded  it ; 
all  we  know  is,  there  is  an  arrest  of  development  in  the  earlier 
months  of  foetal  life. 

It  does  not  seem  to  any  extent  to  be  entailed  or  transmitted  to 
offspring.  In  but  t'aw  instances  which  have  been  brought  to  my 
knowledge  has  there  been  any  evidence  that  the  defective  organi- 
zation was  inherited.  In  some  instances  it  has  appeared  in  several 
children  of  the  same  parents ;  but  in  a  large  majority  of  cases 

1 


they  are  the  solitary  instances  in  the  family.  Neither  is  there 
any  uniformity  in  its  extent.  If  we  take  the  uvula  as  the  start- 
ing-point, we  sometimes  find  merely  a  bifurcation  of  that  organ, 
and  from  this  very  slight  defect  it  is  presented  with  every  grada- 
tion of  extent  into  the  velum,  to  the  posterior  edge  of  the  pala- 
tine bones,  to  the  base  of  the  alveolar  ridge,  and  sometimes 
dividing  the  maxilla  along  the  line  of  either  or  both  the  nasal 
passages. 

The  only  evils  arising  from  this  deformity  worthy  of  our  atten- 
tion are  its  influence  on  deglutition  and  articulation.  These 
functions  being  unlike  each  other,  in  the  fact  that  the  former  is 
natural,  while  the  latter  is  an  acquired  or  a  mechanical  function, 
it  will  readily  be  seen  that  the  loss  of  any  of  the  organs  con- 
cerned may  influence  the  two  in  a  very  different  manner.  A  per- 
son suffering  from  a  congenital  defect  of  an  organ  concerned  in  a 
natural  function,  may,  by  repeated  efforts,  acquire  such  control 
over  the  remaining  organs,  as  to  experience  no  real  discomfort 
from  their  defect.  So,  with  a  child  born  with  a  defective  velum 
or  palate,  it  must,  of  necessity,  find  the  function  of  deglutition 
during  all  the  earlier  period  of  its  life,  and  especially  while  it  is 
dependent  upon  fluids  for  nourishment,  much  impaired.  To  such 
an  extent  have  these  poor  unfortunates  suffered  from  this  defor- 
mity, that  there  is  no  doubt  many  lives  have  been  sacrificed 
solely  from  want  of  nourishment.  But  when  the  deformity  is 
discovered  by  the  nurse,  and  accommodation  made  to  meet  the 
child's  condition,  it  is  very  soon  able  to  obtain  all  the  food  neces- 
sary to  its  development,  and  long  before  it  has  attained  years  of 
discretion  it  has  obtained  such  control  over  the  remaining  organs 
of  deglutition  as  never  to  experience  any  great  discomfort  from 
the  defect.  I  have  never  conversed  with  an  intelligent  patient 
who  was  troubled  with  a  regurgitation  of  food,  either  fluid  or 
solid,  imless  the  head  was  inclined  considerably  forward.  In  fact 
the  physical  comfort  of  an  adult  patient  with  congenital  fissure  of 
the  palate  is  in  no  way  seriously  impaired. 

But  in  regard  to  the  mechanical  function — that  of  making  arti- 
culate sounds — it  is  quite  another  thing.  The  perfection  of  speech 
being  dependent  entirely  upon  the  intelligent  use  of  perfect 
organs  of  speech,  it  follows,  as  a  necessary  consequence,  that  no 
amount  of  repeated  efforts  or  practice  can  make  up  for  the 
absence  of  organs  essential  to  that  acquirement.  It  follows, 
also,  that  nothing  can  produce  this  result  short  of  restoring  to  a 
certain  degree  of  perfection  the  defective  organs.  We  can, 
therefore,  come  to  no  other  conclusion  than  that  the  only  demand 
for  any  method  of  treatment  is  with  a  view  of  improving  the 
speech. 

It  is  necessary,  before  proceeding  further  with  this  subject, 
that  we  understand  pretty  fully  the  mechanical  action  of  the 
organs  concerned  in  articulation,  and  particularly  the  offices  of 
the  velum ;  also,  for  the  purposes  of  this  discussion,  I  desire  to 


draw  a  marked  distinction  between  voice  and  speech.  The  terms 
are  often  confounded,  even  by  learned  men,  when  treating  of 
this  subject,  in  a  manner  which  seems  to  me  unjustifiable. 

The  term  "  voice  "  is  in  common  use  when  speech  is  undoubt- 
edly meant,  and  to  such  an  extent,  that  in  reading  the  works  of 
authors  on  this  subject,  it  is  sometimes  difficult  to  know  whether 
it  is  simply  an  improvement  of  voice  they  refer  to,  or  whether 
the  term  is  meant  to  include  articulation.  By  this  explanation 
only  can  I  reconcile  some  apparent  impossibilities. 

For  the  present,  therefore,  let  us  consider  the  term  "  voice  "  as 
applying  to  all  the  elementary  sounds  of  language  formed  in  the 
larynx,  and  speech  as  applying  to  the  modulations  of  such 
sounds,  by  the  organs  situated  between  the  pharynx  and  lips 
inclusive.     The  voice  is  not  affected  by  a  fissured  velum. 

It  does  not  seriously  interfere  with  vocalization.  With  an  ear 
for  music,  a  person  afflicted  with  this  deformity  may  be  educated 
to  the  production  of  all  the  harmonious  sounds  of  vocal  music. 

Singing,  then,  is  not  necessarily  peculiar,  but  all  those  elemen- 
tary sounds  of  articulate  language  which  are  modified  to  a  greater 
or  less  degree  by  the  velum,  are  more  or  less  defective,  dependent 
to  some  extent  upon  the  size  of  the  fissure. 

The  foregoing  remarks  apply  to  the  voice  as  affected  by  a  cleft 
palate,  when  it  is  not  complicated  with  hare-lip. 

The  influence  of  hare-lip  upon  the  voice  is  marked  and  pecu- 
liar when  associated  with  a  fissured  velum.  I  have  seen  a  few 
cases  where  the  deformity  was  confined  entirely  to  a  fissure  of 
the  lip,  extending  into  one  of  the  nostrils,  but  they  were  all  adult 
cases,  and  such  admirable  operations  had  been  performed  in 
childhood  upon  the  lip  in  each  case,  that  there  was  not  the  slight- 
est defect  of  articulation  or  peculiarity  in  the  tone  of  the  voice. 
But  hare-lip,  when  associated  with  cleft  palate,  may  be  considered 
as  a  prolongation  of  the  cleft  extending  forward,  following  the 
channel  of  one  or  both  nares,  and  terminating  in  an  enlarged 
nostril  and  a  divided  lip.  The  enlarged  naris  and  distended  nos- 
tril give  a  peculiar  and  unpleasant  tone  to  the  voice.  I  would 
therefore  urge  upon  surgeons  in  operating  for  hare-lip,  the  neces- 
sity of  contracting  the  nostril  to  as  nearly  as  possible  the  natural  size. 

It  is  of  much  more  importance  to  the  patient  that  the  size  of 
the  nostril  should  be  reduced  than  that  there  should  be  a  uniform 
border  obtained  to  the  lip. 

If  there  should  be  a  small  notch  left  in  the  edge  of  the  lip  from 
a  defective  union,  the  lower  lip  will  be  able  to  meet  it  and  close 
the  oval  opening ;  but  if  an  unnaturally  large  nostril  is  left,  the 
compressor  nasi  muscle  will  not  have  the  power  to  close  it,  and 
thus  assist  in  the  formation  of  sounds  that  belong  to  articulate 
language. 

It  is  the  modifications  of  the  voice,  by  the  organs  before 
alluded  to,  which  come  to  be  understood  in  the  process  of  time, 
as  speech.     Articulate  language,  therefore,  to  be  clear,  distinct, 


and  uniform,  must  be  the  result  of  the  intelligent  use  of  compa- 
ratively perfect  organs.  The  improper  use  of  or  the  absence  of 
perfect  organs  can  only  result  in  defective- articulation. 

I  am  surprised  that  this  matter  should  have  been  overlooked 
in  many  instances  by  professed  elocutionists. 

I  have  known  professors  of  elocution  receive  as  pupils  persons 
suffering  from  defective  organs  of  speech,  with  the  encourage- 
ment of  perfect  articulation  held  out  as  the  result  of  education. 
It  is  physically  impossible  for  such  a  result  to  follow  under  such 
circumstances.  So  far  as  I  have  read,  it  seems  to  me  too  little 
credit  has  been  given  to  the  velum,  by  physiologists,  as  an  organ 
of  speech.  I  would,  therefore,  claim  for  it  that  it  exercises  a 
more  important  office  in  the  modulation  of  sound  than  any  other 
organ  except  the  tongue.  By  it,  in  conjunction  with  the  pha- 
rynx, the  voice  is  directed  entirely  through  the  oral  cavity.  By 
it,  in  conjunction  with  the  tongue,  the  voice  may  be  directed 
entirely  through  the  nasal  cavity ;  and  by  it  the  voice  may  be 
divided  and  directed  through  both  channels.  On  it  depend  the 
tongue,  teeth,  lips,  and  other  organs  of  speech  of  the  oral  cavity 
for  their  current  of  voice,  out  of  which  to  make  articulate  lan- 
guage. It  is  essential  to  the  purity  of  any  spoken  language  with 
which  the  writer  is  acquainted,  that,  to  produce  certain  sounds, 
the  passage  from  the  pharynx  to  the  posterior  nares  should,  at 
times,  be  entirely  closed,  while  for  other  sounds  it  should  be 
entirely  open,  permitting  the  whole  voice  to  -pass  in  that  direc- 
tion. And  in  this  connexion  let  me  not  be  understood  as  con- 
founding the  uvula  with  the  velum.  So  far  as  my  observations 
extend,  the  uvula  exercises  no  control  over  the  voice  ;  and  so  far 
as  any  injury  to  articulation  might  follow,  the  uvula  may  be 
entirely  removed,  providing  the  velum  and  the  pharynx  have  the 
power  of  closing  the  posterior  nares. 

Let  us  for  a  moment  illustrate  this  point  by  a  single  diagram, 
for  I  maintain  that  upon  the  thorough  understanding  of  this 
principle  must  be  founded  all  intelligent  treatment  of  congenital 
cleft  palate.  Let  us  consider,  then,  the  passage  from  the  glottis 
through  the  mouth,  and  through  the  nares,  as  a  single  and  sim- 
ple musical  wild  instrument.  This  diagram  of  a  supposed  musical 
instrument  will  more  fully  illustrate  my  meaning.  A,  may  be 
called  the  larnyx  or  glottis,  where  the  sound  is  produced  ;  B, 
the  pharynx ;  F,  the  mouth  ;  E,  the  nares ;  D,  a  permanent  par- 
tition (the  palate) ;  C,  a  valve  hung  on  a  hinge  at  the  edge  of 
the  palate  ;  D,  representing  the  velum  with  its  free  end  under 
such  control  as  to  direct  the  sound  at  will,  either  through  the 
nares,  E,  the  mouth,  F,  or  divide  and  direct  through  both. 

Admitting  that  such  an  instrument  as  this  might  be  capable  of 
producing  harmonious  sounds,  it  follows  that  all  instruments 
made  uniform  with  it  would  produce  uniform  results ;  but  let 
a  new  opening  be  made  for  the  escape  of  sound,  for  instance, 
through   the  valve  C,  and  the  capabilities  of  the  instrument   are 


destroyed.    It  is  no  longer   possible  for  it  to  produce  the  same 
result. 

It  is  no  stretch  of  the  imagination  to  say  that  the  principle 
applied  to  the  above-described  instrument  will  apply  with  just  as 


much  force  to  the  natural  musical  organs.  "With  congenital  fis- 
sure of  the  palate  it  is,  therefore,  physically  impossible  for  a  per- 
son to  speak  the  same  language  as  those  with  perfect  organs  ; 
and  in  this  way  only,  in  many  cases,  is  this  deformity  betrayed  to' 
the  society  in  which  the  person  moves. 

It  becomes  us,  therefore,  not  only  as  a  matter  of  professional 
pride,  but  on  far  higher  and  more  noble  grounds — those  of 
philanthropy,  of  sympathy  with  a  class  of  unfortunates,  in  many 
cases  as  intelligent,  as  refined,  and  as  sensitive  as  their  more 
fortunate  neighbors,  though  deprived  by  nature  of  one  of  the 
most  delightful  acquirements  of  man — it  becomes  us  to  use  every 
means  in  our  power,  not  to  perform  brilliant  operations  merely  to 
gratify  our  pride,  but  to  accept  and  use  all  such  means,  and  only 
such  means,  as  shall  give  hope  of  their  restoration  to  society.  I 
hold  it  to  be  the  bounden  duty  of  every  professional  man  to  seek, 
by  the  use  of  every  means  within  his  reach,  the  highest  good  of 
his  patients.  He  has  not  discharged  his  obligation  when  he 
accepts  a  trust,  until  all  has  been  accomplished  that  human  aid 
can  give.  It  is  not  uncommonly  the  case  that  a  practice  is  con- 
tinued because  it  has  grown  venerable  with  age,  and  will  not 
yield  to  a  better  method  through  jealousy  or  pride.  The  patient, 
then,  must  be  the  sufferer. 

Such  a  course  will  unquestionably,  sooner  or  latei-,  degrade  the 
profession.  Neither  is  any  man  justified  in  adopting  any  method 
of  treatment  which,  however  successful  the  result  may  be,  inflicts 
unnecessary  pain.  It  is  not  possible  in  our  profession,  or  that  of 
surgery,  to  which  it  is  so  nearly  allied,  to  always  render  the  best 
of  services  without  the  infliction  of  severe  pain;  but  it  is  possible, 
by  delicacy  of  manipulation  and  by  consummate  skill,  the  result 
of  practice,  to  lessen  the  severity  of  suffering,  and  bring  it  within 
the  forbearance  of  the  patient.  This  matter  of  relief  from  the 
infliction  of  pain  is,  I  fear,  too  little  considered  by  our  profession, 
and  from  it  has,  not  unnaturally,  grown  up  the  dread  of  the 
"  horrid  Dentist."  There  is  a  gentleness  of  touch,  a  freedom  from 
pain,  in  our  operations,  which   is   not   all  inconsistent  with   tho- 


roughness.  When  two  methods  of  treatment  present  themselves, 
admitting  that  either  promises  the  same  result,  we  are  not  justi- 
fied in  adopting  one  which  may  entail  suffering  on  the  j)atient, 
while  the  other  is  open  to  us  with  entire  freedom  from  it. ' 

In  the  treatment  of  fissured  palate,  the  operation  of  staphylo- 
raphy  has  long  held  its  rank  as  the  treatment  par  excellence  for 
this  deformity,  and,  although  during  all  the  earlier  years  of  its 
history  it  was  accompanied  with  varying  success,  it  has,  never- 
theless, been  called  in  practice  so  often  that,  in  a  surgical  sense, 
little  else  can  be  desired  or  hoped  for.  That  this  should  seem  at 
first  the  most  desirable  treatment  for  fissured  palate  all  must 
admit.  A  patient  is'  presented  with  a  concealed  deformity,  but 
his  speech  betrays  him.  An  examination  discloses  the  fact, 
that  the  membranous  curtain  which  divides  the  oral  from  the 
nasal  cavity  is  split  from  uvula  to  palatine  bone  ;  but  its  sides  are 
soft  and  elastic,  and  it  is  observed  in  the  process  of  deglutition 
that  the  sides  of  the  cleft  approach  and  come  in  contact  with 
each  other.  What  more  natural,  then,  than  the  suggestion  to 
pare  the  edges  of  the  cleft  and  unite  them  by  suture,  and  thus 
form  a  perfect  septum  in  place  of  an  impaired  one  ? 

I  will  not  here  go  into  an  analysis  of  the  different  methods  of 
performing  that  operation  now  practised  by  various  surgeons. 
Mr.  Fergusson,  F.R.C.S.,  F.R.S.,  of  London,  is  now  universally 
recognised  as  having  had  greater  experience  than  any  other  sur- 
geon who  ever  lived.  I  speak  from  memory  when  -I  say  that  he 
has  operated  on  about  two  hundred  and  fifty  cases,  and  claims,  I 
believe,  that  nearly  every  one  was  a  success ;  that  is,  in  a  surgical 
sense,  he  had  obtained  some  union,  either  partial  or  complete,  in 
all  these  cases  but  two  or  three. 

As  a  rule,  he  divides  the  levatores  palati  on  either  side,  so  as  to 
destroy  the  tension  on  the  sutures. 

Mr.  Pollock,  F.R.C.S.,  surgeon  to  St.  George's  Hospital,  Lon- 
don, has  probably  performed  the  operation  as  often  as  any  other 
man,  with  the  exception  of  Mr.  Fergusson. 

I  had  the  pleasure  of  frequent  conversations  with  him  upon 
this  topic  within  the  past  year,  and  although  possessing  consummate 
skill,  and  ranking  as  high  as  any  surgeon  in  Great  Britain,  he 
does  not  claim  for  himself  such  unvarying  success  as  does  Mr. 
Fergusson.  His  method  varies  somewhat  from  Fergusson's,  but 
he  nevertheless  divides  the  same  muscle  and  arrives  virtually  at 
the  same  result. 

Other  operators  of  London  are  more  or  less  imitators  of  the 
foregoing.  I  was  introduced  by  Professor  Syme  of  Edinburgh  to 
a  pupil  of  his,  Professor  Annandale,  also  of  Edinburgh,  a  young 
man  of  fine  promise,  who  has  recently  met  with  much  success  in 
his  operations  for  this  deformity  on  a  different  and  what  I  con- 
ceive to  be,  when  practicable,  a  far  better  method.  His  opera- 
tion consists  in  making  an  incision  in  the  mucous  membrane 
parallel  with  the  lingual  surfaces  of  the  teeth,  and  dissecting  off 


I 


the  tissue,  finds  it  sufficiently  relaxed  to  bring  the  edges  of  the 
fissure  together,  when  they  are  united  in  the  usual  way.  He 
claims  his  ability  by  this  method  to  not  only  obtain  a  union  with- 
out the  destruction  of  any  muscle,  but  to  obtain  also  a  deposition 
of  bone  by  the  bridging  over  of  the  fissure  in  the  hard  palate 
with  the  periosteum  dissected  off  and  drawn  from  the  sides.  He 
has  to  all  appearance  accomplished  this  in  more  than  one  instance. 

In  Paris,  while  the  operation  of  staphyloraphy  was  first  accom- 
plished by  a  Frenchman,  and  while  the  hospitals  of  Paris  boast  of 
some  of  the  most  skillful  surgeons  living,  this  operation  has  been 
almost  if  not  entirely  abandoned. 

In  our  own  country,  so  far  as  I  can  learn,  there  has  been  no 
such  extensive  experience  as  that  recorded  of  the  hospitals  of 
London . 

To  Warren  of  Boston,  and  Mutter  of  Philadelphia,  has  been 
accorded  I  believe  the  most  experience  of  any  in  the  country. 
But  either  the  deformity  is  more  rare,  the  cases  more  scattered, 
or  the  aid  of  the"  surgeon  is  not  called  in,  and  thus  no  one  man  has 
acquired  such  extensive  practice  in  this  line  as  have  some  abroad. 
But  thanks  to  all  these  men  and  many  others,  they  have  by  their 
consummate  skill  carried  this  operation  to  such  a  state  of  perfection 
that  they  have  proved  all  that  can  ever  be  claimed  for  it.  What- 
ever may  be  the  future  of  staphyloraphy,  their  operations  will 
form  a  brilliant  page  in  the  history  of  surgery. 

I  have  dwelt  at  some  length  in  the  beginning  of  this  paper  on 
the  only  object  of  any  treatment  of  congenital  cleft  palate,  being 
vv'ith  a  view  of  improving  articulation.  How  will  staphyloraphy 
stand  the  test  ?  Has  it,  as  a  rule,  enabled  the  patient  to  conceal 
the  evidence  of  the  deformity  from  society  ?  Or,  in  other  words, 
has  it  proved  in  any  number  of  cases  that  it  can  be  relied  upon  to 
enable  a  patient  to  articulate  so  clearly  and  distinctly  as  not  to 
continually  betray  the  defect?  That  it  does  improve  articulation 
in  many  cases  somewhat,  and  perhaps  all  more  or  less,  all  candid 
minds  must  admit,  from  the  abundant  statements  to  that  effect. 
But  if  there  is  no  serious  difficulty  experienced  from  a  fissured 
palate  in  deglutition,  and  the  only  discomfort  worthy  of  notice  is 
the  mortification  arising  from  unintelligible  or  defective  artjcula- 
tion,  how  far  does  limited  improvement  in  speech  answer  the  end 
desired  and  hoped  for,  and  how  far  does  it  justify  a  tedious  and 

i>ainful  operation,  so  long  as  the  deformity  is  still  patent  to  all  ? 
n  this  connexion  let  me  quote  from  the  highest  living  authority.* 
"The  grand  practical  object  of  this  operation  is  to  improve  the 
voice  and  articulation.  Defective  deglutition  from  this  malforma- 
tion  is  what  attracts  the  mother's  or  nurse's  attention  in  early  life. 
The  cries  of  infancy  are  in  nowise  peculiar  in  tone;  but  when  defi- 
nite articulation  commences,  or  rather  should  commence,  the 
value  of  an  entire  palate  i3  then  appreciated.     The  air  and  sound, 

*  Mr.  Fergusson,  F.R.C.S.,  F.R.S.,  June,  1864. 


8 

in  passing  outwards  through  the  larynx,  escape  in  part  through  the 
nostrils  by  the  split  in  the  palate.  A  nasal  twang  is  the  result, 
and  articulation  as  in  the  normal  state  is  impossible.  Immediately 
after  the  operation  the  modification  on  the  voice  can  be  at  once 
detected.  .  .  .  Improved  articulation,  however,  comes  slowly. 
Years,  many  years,  are  required  for  distinct  articulation ;  and  after 
the  most  successful  operation  for  cleft  palate  months  and  years 
are  required  to  alter  defective  sounds.  Voice  and  speech  have  to 
be  modified  anew.  With  some  the  changes  come  slowly  and 
sluggishly ;  but  with  others  they  are  so  rapid  and  perfect  that 
within  a  few  years  the  original  defect  cannot  be  detected  except 
by  a  practised  ear."  Out  of  the  large  number  of  surgical  suc- 
cesses, is  it  a  rule  that  the  patient  is  recompensed  for  the  suffering 
undergone  by  the  result  obtained  ?  I  must  confess  I  have  no 
statistics  to  offer  you  in  answer  to  these  inquiries.  While  I  have 
seen  many  cases  where  there  was  a  good  union  throughout  the 
entire  length  of  the  former  fissure,  I  have  never  seen  one  where 
the  speech  was  not  more  or  less  defective,  nor  where  the  friends 
considered  that  it  was  very  materially  improved.  And  the 
opinions  now  entertained  iu  France  may  be  said  to  perfectly  coin- 
cide with  those  I  have  here  advanced. 

In  the  London  "Lancet"  of  Nov.  19,  1864,  I  find  a  review  of 
an  article  furnished  by  Mr.  Pollock  on  "  Staphyloraphy  "  for  the 
fourth  volume  of  "  Holme's  System  of  Surgery,"  from  which  I 
make  the  following  extract: — "It  is,  we  believe,  a  fact  that  the 
success  which  French  surgeons  have  met  with  in  this  operation 
is  so  indifferent  that  it  is  practically  abandoned  in  the  French 
hospitals,  notwithstanding  the  early  trials  by  which  Roux  connect- 
ed his  illustrious  reputation  with  staphyloraphy.  The  French 
surgeons  now  entertain  the  idea  that,  on  the  whole,  the  defect  is 
best  left  to  mechanicians But  it  is  a  very  doubtful  ques- 
tion whether  surgery  is  exalted  by  thus  surrendering  its  triumphs, 
and  calling  in  the  aid  of  a  mechanist  to  supply  defects  which  may 
be  remedied  by  their  surgical  obliteration.  Surgeons  undertaking 
staphyloraphy  should,  however,  always  bear  in  mind  one  circum- 
stance connected  with  the  results  of  the  operation.  The  most 
complete  success  in  restoring  the  palate  by  union  of  the  cleft  by 
no  means  implies  restoration  of  the  articulation  to  a  natural  or 
intelligible  standard.  Long  after,  or  even  for  ever  after,  the  suc- 
cess of  the  operation,  in  a  surgical  sense,  the  patient  may  continue 
to  speak  in  a  manner  hardly  less  unintelligible  and  disagreeable 
than  before.  The  use  of  the  new  palate  can  only  be  acquired  by 
careful  and  intelligent  practice  in  the  mechanism  of  articulation. 
Much  perseverance  and  careful  tuition,  are  constantly  necessary 
tc  attain  this  end."  I  can  readily  conceive,  however,  of  rare 
presentations,  where,  with  abundance  of  material,  a  long  uvxda 
and  a  good  union,  without  much  injury  to  the  muscles,  clear  and 
distinct  articrdation  ought  to  follow.  Indeed,  I  have  it  upon  the 
very  excellent  authority  of  my  friend  Dr.  Mussey,  of  Cincinnati, 


9 

that  a  patient  of  about  twelve  years  of  age  for  whom  he  operated 
a  few  years  since,  is  now  enabled  by  the  result  of  that  operation 
to  articulate  perfectly.  But  in  a  large  majority  of  cases,  I  think 
I  am  justified  in  saying  that  such  a  result  is  impossible.  My 
reasons  for  so  sweeping  an  assertion  are  as  follows : — The  newly 
formed  septum  is  too  short  at  the  boundary  of  the  fauces,  and 
generally  somewhat  more  depressed  than  it  would  have  been  if  it 
had  united  during  its  formation,  thus  contracting  the  passage 
between  the  tongue  and  the  velum ;  the  power  of  the  levator 
muscle  has  been  much  weakened  by  the  knife  ;  the  newly  formed 
septum  is  either  taut  or  paralysed,  and  from  this  combination  of 
causes  the  passage  through  the  nares  remains  permanently  open, 
thus  permitting  a  large  volume  of  voice  to  escape  without  the 
power  of  the  tongue  to  exercise  any  control  over  or  modify  it. 
The  ability  to  articulate  any  spoken  language  correctly  must 
remain  an  impossibility  so  long  as  the  velum  and  pharynx  are 
unable  to  meet,  and  at  will  shut  off  that  passage.  I  apprehend 
that  on  this  point  alone  rest  all  the  failures  of  whatever  treatment, 
for  the  difficulties  to  be  overcome  at  any  other  point  are  compa- 
ratively slight.  If  staphyloraphy,  then,  comes  so  far  short  of 
accomplishing  in  a  majority  of  cases  all  that  is  desired,  we  are  very 
naturally  led  to  inquire,  is  there  any  hope  from  any  other  source  ? 
Obturators  have  for  a  long  time  been  resorted  to  for  this 
object;  and  when  we  consider  that  probably  the  earlier  appli- 
cations of  this  instrument  were  for  perforations  of  the  palate 
induced  bv  accident  or  disease,  and  that  their  srood  offices  were 
made  apparent  immediately,  it  is  not  to  be  wondered  at  that 
much  was  expected  from  their  use  in  congenital  cases,  and 
especially  so  when  the  true  principle  upon  which  an  instrument 
should  be  adapted  was  so  little  understood.  It  is  hard  to  recon- 
cile the  statements  which  have  passed  into  history  of  the  perfect 
results  obtained  by  their  use  in  congenital  fissure.  An  obturator 
properly  adapted  as  ?>.  bridge  to  span  a  simple  perforation  of  the 
hard  palate,  from  whatever  cause  induced,  will  accomplish  all  that 
any  treatment  can  ;  but  there  its  mission  virtually  ends.  To 
claim  that,  with  a  fissured  velum,  the  gap  can  be  bridged  over, 
or  the  posterior  nares  plugged  and  perfect  articulation  will  follow, 
is  to  claim  an  absurdity — a  total  impossibility.  A  great  deal  of 
ingenuity  has  been  wasted  in  their  construction,  and  the  claims 
for  them  must  have  been  made  in  advance,  without  waiting  for 
the  proof.  In  the  present  state  of  science  and  art  our  only 
remaining  hope  of  relief  is  the  substitution  of  an  elastic  artificial 
appliance  to  fill  up  the  gap.  This  simple  idea  is  not  a  new  one, 
neither  is  the  application  of  it  of  recent  date.  Elastic  artificial 
vela  have  been  made,  or  attempted  to  be  made,  of  some  form  or 
other,  almost  ever  since  the  use  of  india-rubber  for  mechanical 
purposes,  and  I  do  not  know  1ml  of  other  materials  long  before. 
One  thing,  however,  is  certain — the.  application  of  BUitable  elastic 
material  in  skillful  hands  for  the  treatment  of  these  cases  is  capable 


10 

of  producing  far  more  satisfactory  results  than  have  heretofore  been 
derived  from  any  other  source.  The  indications  to  be  fulfilled  by 
such  an  appliance  are — an  obturator,  or  covering  for  the  cleft, 
which  shall  be  perfectly  adapted  to  the  muscles  against  which  it  is 
to  lie  ;  shall  be  flexible,  susceptible  of  all  the  motions  of  the  velum 
or  soft  palate  itself;  shall  be  durable  ;  easily  detached  and  replaced 
by  the  patient ;  and,  in  a  word,  shall  be  so  under  the  control  of 
surrounding  muscles,  when  in  situ,  that  the  patient  has  the  power 


Fig.  1  represents  a  model  of  a  fissured  palate,  complicated  with  hare-lip  on  the  left  of  the 
mesial  line.  There  is  a  division  also  of  the  maxilla  and  the  alveolar  process  :  the  sides  being 
covered  with  mucous  membrane  which  come  in  contact  with  each  other,  hut  ore  not  united. 
Tho  lei't  lateral  incisor  and  left  canine  tooth  are  not  developed. 


Fiff.% 


Fig.  2  represents  the  artificial  v.dum.  as  viewed  from  its  superior  surface,  together  with 
its  attachment  and  two  artificial  teeth  to  fill  the  vacancy. 

The  lettered  portion  of  this  appliance  is  made  of  elastic  vulcanized  rubber;  its  attachment 
to  the  teeth  of  hard  vulcanized  rubber,  to  which  the  velum  is  connected  by  a  stout  gold  pin, 
firmly  imbedded  at  one  end  in  the  hard  rubber  plate.  The  other  end  has  a  head,  marked  C, 
which  being  considerably  larger  than  the  pin.  and  also  the  corresponding  hole  in  the  velum,  it 
is  forced  through — the  elasticity  of  tile  volum  permitting— and  the  two  are  securely  connected. 

The  process,  B,  laps  over  the  superior  surface  of  the  maxilla  (the  floor  of  the  naris),  and 
effectually  prevents  all  inclination  to  droop. 

The  wings,  A  A,  reach  across  the  pharynx,  at  the  base  of  the  chamber  of  the  pharynx, 
behind  the  remnant  of  the  natural  velum. 

The  wings,  DD,  rest  upon  the  opposite  or  anterior  surface  of  the  soft  palate. 


11 


Fig.  3  represents  a  model  the  same  as  Fig.  1,  with  the  appliance,  Fig.  2,  in  situ. 
The  wings,  DD,  in  Fig.  2,  and  the  posterior  end  of  the  artificial  velum  only,  in  this  cut 
being  visibleT 

which  in  a  normal  state  he  would  possess,  of  directing  the  voice 
at  will  either  through  the  mouth  or  the  nasal  cavity,  or  both,  as 
desired. 

Such  an  instrument  as  that  described  has  been  brought  to 
such  a  state  of  perfection  that  I  have  no  hesitation  in  saying  that 
it  can  be  adapted  to  any  case  of  congenital  fissure  of  the  velum 
that  is  usually  seen,  whether  complicated  with  a  fissure  of  the 
maxilla  or  not.  It  can  be  made  so  as  to  be  retained  in  situ, 
without  danger  of  misplacement ;  can  be  worn  all  the  time  from 
the  first  hour  without  discomfort;  is  capable  of  being  raised  and 
depressed,  also  to  allow  the  sides  of  the  fissure  to  contract  (as  in 
the  process  of  deglutition)  without  interference,  and  is  so  simple 
that  a  child  cannot  disarrange  it  to  its  detriment.  Such  an  appli- 
ance renders  it  perfectly  possible  for  the  patient  to  learn  to  speak 
well. 

The  physical  and  mechanical  difficulties  to  be  overcome  in  the 


The  mechanical  manipulations  necessary  in  the  construction  of  this  instru- 
ment were  described  extemporaneously  at  the  second  meeting  of  the  Society 
given  to  this  subject,  and  held  October  4th. 

It  will  be  impossible  to  reproduce  those  remarks  in  full  in  connexion  with 
this  paper,  but  they  were  based  upon  the  description  already  given  to  the  pro- 
fession, and  found,  in  the  last  number  of  "Harris'  Dental  Surgery."  The 
method  there  described  is  the  same  in  all  essential  particulars  as  now  used, 
the  only  important  difference  bei.ig  in  the  form  of  the  instrument,  which  will 
be  readily  apprehended  by  a  comparison  of  the  illustrations  in  that  woik 
with  those  in  this;  but  the  manner  of  producing  it,  with  some  unimportant 
variations,  being  the  same. 


12 

adaptation  of  this  artificial  velum  are  a  serious  obstacle  to  the 
operator,  for  on  the  nice  adjustment  of  the  instrument  to  all  the 
parts  surrounding  the  fissure  depends  entirely  the  comfort  with 
which  the  patient  wears  it,  and  the  consequent  use  he  will  make 
of  it. 

The  movements  produced  by  the  superior  constrictor  muscle 
of  the  pharynx  upon  the  remnant  of  the  velum  in  the  act  of 
deglutition  will  be  remembered.  In  the  proper  adaptation  of  an 
appliance  arrangement  should  be  made  for  this  movement.  If 
not  provided  for,  the  act  of  deglutition  would  compel  it  to  fold 
upon  itself,  and  thus  interfere  with  that  function ;  or,  if  too 
unyielding,  it  would  irritate  the  surrounding  tissues,  until  it  could 
not  be  borne. 

It  is  so  delicate  in  its  structure  that  I  have  never  known  a 
single  instance  of  irritation  or  inflammation  of  the  tissue  in  contact 
with  it  when  properly  adapted. 

It  is  supported  in  situ  by  resting  on  the  superior  surface  of  the 
palatine  or  maxillary  bone  in  the  vicinity  of  the  apex  of  the  fis- 
sure. It  is  retained  by  a  very  simple  attachment  of  gold  connected 
with  it  near  its  apex,  and  reaching  to  one  or  two  of  the  teeth, 
with  sufficient  hold  around  the  tooth  to  prevent  its  slipping  off. 
But  even  the  presence  of  natural  teeth  is  not  essential  to  retain  it 
firmly  and  properly  in  its  position,  as  in  one  case  which  I  had 
under  treatment  the  patient  had  not  a  natural  tooth  in  her  mouth, 
and  an  entire  upper  and  under  set  of  artificial  teeth  was  adapted, 
and  to  the  upper  set  of  teeth  was  attached  the  artificial  palate, 
which  was  worn  with  as  much  satisfaction  as  any  case  that  has 
come  under  my  observation. 

There  are  many  points  of  physiological  importance  developed 
by  this  experience,  Avhich  would  be  most  interesting  to  dwell 
upon  did  not  limited  time  prevent  my  presenting  them  in  full. 
To  some  of  them,  however,  I  must  briefly  recur. 

The  intellectual  capacity  of  the  patient  exercises  a  greater  con- 
trol over  the  rapidity  and  amount  of  improvement  than  the  pecu- 
liar physical  conformation  of  the  defect.  A  musical  ear,  cultivated 
to  a  nice  distinction  of  sounds,  is  of  material  benefit  in  making  the 
most  of  this  appliance.  The  age  should  also  be  taken  into  con- 
sideration, and  as  early  an  age  as  the  patient  would  take  an  inte- 
rest in  developing  its  benefit  would  undoubtedly  be  preferable. 

The  improper  position  in  which  some  of  the  organs  of  speech 
are  placed  in  the  efforts  of  the  patient  to  articulate  distinctly 
becomes  so  habitual  as  to  be  almost  impossible  to  overcome,  and 
manifestly  the  earlier  the  age  at  which  this  is  attempted,  before 
these  habits  become  firmly  fixed,  the  better.  I  have,  however, 
in  one  instance,  adapted  an  instrument  for  a  patient  over  thirty 
years  of  age,  and  in  another  for  one  over  forty  years  of  age,  both 
of  whom  derived  very  marked  benefit  from  its  use  within  a  very 
few  months. 

The  earliest  age  to  which  I  have  adapted  these  appliances  is 


13 

eight  years,  and  of  all  ages  varying  between  these  extremes. 
Again,  the  sensitiveness  of  individuals  to  the  defect,  the  mor- 
tification experienced  in  the  exposure  by  their  speech  of  this 
deformity,  will  prove  a  powerful  incentive  to  their  practice  and 
the  consequent  rapidity  of  their  improvement. 

It  is  astonishing  with  what  entire  freedom  from  discomfort  or 
annoyance  thy  velum  is  worn  immediately  on  its  introduction.  I 
have  bad  but  two  patients  in  whom  there  was  any  irritation 
or  inflammation  in  consequence  of  wearing  it ;  and  in  those  two  it 
passed  away  entirely  within  a  day  or  two,  and  only  in  rare  cases 
have  they  ever  experienced  even  a  lameness  of  the  surrounding 
muscles. 

It  will  naturally  be  asked,  what  has  been  the  result  of  this 
treatment  in  any  number  of  cases.  I  can  state  most  confidently, 
a  decided  improvement  in  speech  within  a  very  few  weeks,  a 
clearness  and  distinctness  of  utterance  which  the  patient  never 
showed  before.  In  some  cases  this  progress  has  been  so  rapid 
that,  within  a  period  of  six  months  after  its  first  introduction,  the 
wearer  would  not  from  his  speech  be  suspected  by  the  ordinary 
observer  of  possessing  such  a  deformity  ;  and  in  every  case,  within 
a  few  months  the  speech  has  improved  so  much  as  to  render  it 
perfectly  intelligible  to  strangers  without  repetition.  It  must  not 
be  supposed  from  these  statements  that  there  is  any  marked 
change  in  articulation  immediately.  There  is  almost  always  an 
immediate  change  in  the  tone  of  the  voice,  which  is  much  less 
disagreeable  than  formerly,  and  this  change  is  often  mistaken  for 
an  improvement  in  articulation. 

I  desire  to  be  distinctly  understood,  that  the  remarks  in  this 
paper  apply  to  cases  of  congenital  cleft  only.  I  have  referred 
only  incidentally  to  fissured  palate,  from  any  other  cause  induced. 
I  am  thus  careful  to  make  this  distinction  because  the  application 
of  an  instrument  to  any  other  than  congenital  cases  is  so  compa- 
ratively simple,  and  the  results  so  quick  to  manifest  themselves, 
that  it  forms  no  criterion  by  which  to  jndge  of  the  treatment  of 
congenital  fissure.  A  person  who  has  once  possessed  the  power 
of  distinct  articulation,  may  lose  to  a  certain  extent  some  of  the 
organs  concerned  in  that  function,  and  the  remaining  organs  may 
be  so  developed  as  to  completely  hide  the  loss.  The  educated 
ear  then  seems  to  exercise  such  a  power  over  the  defective  organs 
as  to  develop  an  extraordinary  usefulness.  These  malformations 
are  manifested  much  more  in  the  attempt  to  articulate  some  lan- 
guages than  others. 

There  is  a  most  interesting  field  of  inquiry  for  the  physiologist 
growing  out  of  this  subject,  to  which  I  have  neither  the  time  nor 
the  ability  to  do  justice.     I  can  only  glance  at  it. 

In  the  articulation  of  the  Anglo-Saxon  tongue  the  compressor 
nasi  muscle  is  very  seldom,  if  ever,  called  into  requisition.  In 
the  cases  of  deformity  which  we  have*  been  considering,  the 
escape  of  voice  through  the  nostrils  is  so  great  that  the  individual 


14 

very  soon  forms  the  habit  of  using  that  muscle  constantly.  The 
result  is,  he  acquires  the  power  of  making  such  sounds  as  do  not 
belong  to  our  language,  but  which  nevertheless  do  form  a  very 
prominent  part  of  other  cultivated  tongues.  That  muscle  is  much 
more  frequently  used  in  speaking  the  French  language  than  our 
own.  It  will  be  readily  understood,  then,  that  these  persons 
(other  things  being  equal)  can  much  sooner  learn  to  speak  the 
French  language  correctly  than  our  own.  With  that  language 
that  habit  assists  them,  with  our  own  it  must  be  broken  up.  It 
must  also  be  borne  in  mind  that  it  is  much  more  difficult  to  break 
up  the  habit,  when  fully  formed,  of  speaking  a  language  badly 
than  to  acquire  the  power  of  speaking  a  new  one  correctly.  The 
Irishman  can  much  sooner  master  a  foreign  language  than  he  can 
correct  the  brogue  with  which  he  speaks  his  native  tongue. 

In  some  of  the  cases  which  we  have  had  under  consideration  it 
has  already  been  proved  that  they  learn  to  master  a  foreign  lan- 
guage even  more  readily  than  their  own. 

In  all  cases  where  patients  have  been  under  treatment  either 
by  surgical  or  mechanical  means,  I  would  urgently  recommend  a 
course  of  practice  which  would  tend  to  develop  the  latent 
powers.  A  course  of  lessons  in  articulation  from  a  competent 
instructor,  or  the  study  of  a  foreign  language,  would  be  admira- 
bly adapted  to  that  end. 

In  conclusion,  I  desire  to  add  a  brief  extract  from  some 
remarks  made  by  Mr.  Pollock  before  the  Odontological  Society 
of  London  on  this  subject  during  the  past  year : — 

"Mb.  Pollock — As  one  who  has  taken  some  little  interest  in 
the  question  of  congenital  cleft  palate,  I  consider  it  my  duty  to 
rise  to  pay  my  tribute  of  respect  and  admiration  to  Dr.  Kingsley 
for  the  very  eminently  practical  and  ingenious  apparatus  which 
he  has  brought  before  us  this  evening.  I  look  upon  it  as  one  of  a 
series  of  those  very  great  improvements  that  have  come  from  the 
other  side  of  the  Atlantic,  which  have  conferred  so  much  benefit 
on  mankind.  I  cannot  but  feel,  from  the  experience  I  have'  had 
in  the  treatment  of  congenital  cleft  palate,  that  the  operation  for 
closing  it  by  surgical  means  is  not  always  a  satisfactory  operation. 
There  are  a  few  cases  which  certainly  offer  every  facility  and 
every  advantage  for  the  operation,  and  in  those  few  cases  we  do 
succeed,  in  time,  in  procuring  a  considerable  amelioration,  if  not 
almost  perfection  in  articulation.  I  have  in  many  cases  observed 
a  considerable  improvement,  I  might  almost  say,  an  immediate 
improvement  in  the  voice,  and  a  subsequent  and  slow,  but  a  very 
uncertain,  improvement  in  the  articulation.  There  is  very  often 
a  large  aperture  between  the  mouth  and  the  nares,  which  pro- 
duces a  most  disagreeable  cavernous  resonant  sound  in  the  voice. 
That  has  been  very  much  modified  by  operation  in  more  than  one 
instance,  without,  I  may  say,  much  material  improvement  in  the 
articulation.  So  much  with  regard  to  the  operation  ;  but  I  am 
sure  everybody  in  this  room  who  has  witnessed  any  number  of 


15 

congenital  clefts  will  feel  with  me,  that  there  is  a  class  of  cases 
in  which  a  surgeon  would  not  only  be  rash,  but  he  would  be  very 
much  to  blame  if  he  undertook  an  operation.  I  allude  to  those 
cases  in  which  the  soft  palate  is  what  you  may  call  thin  and  defi- 
cient in  quantity,  in  which  the  uvula  is  but  a  small  point  project- 
ing on  either  side  from  a  little  curtain,  which  is  drawn  up  on  each 
side  of  the  fauces.  I  have  myself  refused  to  operate  in  more 
than  one  such  instance.  *  *  *  I  have  seen  cases  with  simple  cleft  of 
the  uvula,  defective  in  voice,  and  I  have  seen  simple  loss  of  the 
uvula  produce  defective  voice.  Whether  it  is  that  a  certain 
escape  takes  place  through  the  congenital  cleft  of  the  uvula,  or 
whether  it  is  that  the  contraction  subsequent  to  ulceration  pro- 
duces general  contraction  of  the  velum  I  am  not  prepared  to  say  ; 
but  of  the  fact  there  is  no  doubt,  that  with  deficient  uvula  there 
is  very  often  a  defective  voice.  This  apparatus  of  Dr.  Kingsley's 
seems,  as  far  as  possible,  I  think,  to  meet  the  general  require- 
ments of  the  soft  as  well  as  the  hard  palate.  It  has  the  capability 
of  adapting  itself  to  the  movements  of  the  soft  palate,  either  of 
stretching  out  to  the  extreme,  that  is  required,  or  of  contracting 
by  folding  over  upon  itself,  and  in  this  way  I  must  say  that  I  am 
rather  inclined  to  give  my  verdict  in  favor  of  Dr.  Kingsley's 
apparatus  for  the  treatment  of  congenital  cleft  palate." 


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